Objectives To characterize the use of mechanical ventilation in the emergency department (ED), with respect to ventilator settings, monitoring, and titration; and to determine the incidence of progression to acute lung injury (ALI) after admission, examining the influence of factors present in the ED on ALI progression. Methods This was a retrospective, observational cohort study of mechanically ventilated patients with severe sepsis and septic shock (June 2005 to May 2010), presenting to an academic ED with an annual census of >95,000 patients. All patients in the study (n = 251) were analyzed for characterization of mechanical ventilation use in the ED. The primary outcome variable of interest was the incidence of ALI progression after ICU admission from the ED and risk factors present in the ED associated with this outcome. Secondary analyses included ALI present in the ED and clinical outcomes comparing all patients progressing to ALI versus no ALI. To assess predictors of progression to ALI, statistically significant variables in univariable analyses at a p ≤ 0.10 level were candidates for inclusion in a bidirectional, stepwise, multivariable logistic regression analysis. Results Lung-protective ventilation was used in 68 patients (27.1%), and did not differ based on ALI status. Delivered tidal volume was highly variable, with a median tidal volume delivered of 8.8 mL/kg ideal body weight (IBW) (IQR 7.8 to 10.0), and a range of 5.2 to 14.6 mL/kg IBW. Sixty-nine patients (27.5%) in the entire cohort progressed to ALI after admission to the hospital, with a mean onset of 2.1 days (SD ± 1 day). Multivariable logistic regression analysis demonstrated that a higher body mass index, higher Sequential Organ Failure Assessment score, and ED vasopressor use were associated with progression to ALI. There was no association between ED ventilator settings and progression to ALI. Compared to patients who did not progress to ALI, patients progressing to ALI after admission from the ED had an increase in mechanical ventilator duration, vasopressor dependence, and hospital length of stay. Conclusions Lung-protective ventilation is uncommon in the ED, regardless of ALI status. Given the frequency of ALI in the ED, the progression shortly after ICU admission, and the clinical consequences of this syndrome, the effect of ED-based interventions aimed at reducing the sequelae of ALI should be investigated further.

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Mandible fractures are the most common result of facial trauma. The proximity of oral flora to the site of both the injury and resulting surgical instrumentation makes managing infection a unique challenge. The benefit of antibiotic prophylaxis at the time of surgical treatment of mandible fractures is well established. However, the routine use of antibiotics between the time of injury and surgery is of unclear benefit. We aim to define the role of antibiotics in the preoperative period: from the time of injury to surgical intervention. Demographic and clinical data were collected retrospectively on all patients who were treated for mandible fracture by the Division of Plastic and Reconstructive Surgery at our institution between 2003 and 2013. The use of both preoperative (between injury and surgery) and perioperative (at the time of surgery) systemic antibiotics was recorded along with the incidence of postoperative infections and other complications. Complete data were available for 269 patients. Of the 216 patients who received preoperative antibiotics, 22 (10%) developed an infection postoperatively. Of the 53 patients who did not receive preoperative antibiotics, 2 (4%) developed infection ( = 0.184). Likewise, preoperative antibiotics were not significantly associated with hardware complication rates. In our retrospective review, the use of antibiotics between injury and surgical repair had no impact on postoperative infection rates. These data suggest that preoperative antibiotic use may actually be associated with an increased incidence of postoperative infection. Our results do not support the routine use of antibiotics between injury and surgical repair in patients with mandible fractures.

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